MAS
Form
4AT / Application for Further Assessment of a Treatment Dispute by the Medical Assessment Service /
Under section 62(1)(a) of the Motor Accidents Compensation Act 1999
This form is approved by the Motor Accidents Authority in accordance with clause 14.1 of the Medical Assessment Guidelines.
Use this form only if:
·  The specific medical dispute has previously been assessed by a MAS Assessor;
·  There has been deterioration and/or there is additional relevant information about the injury or injuries sustained in the motor vehicle accident and the deterioration and/or additional information is such as to be capable of having a material effect on the outcome of the previous assessment;
·  All certificates pertaining to that dispute have been issued (including combined certificates and Review Panel certificates);
·  The time period for lodging an application for either a correction of an obvious error or Review, arising from the original assessment of that dispute has expired; and
·  Any application for correction of an obvious error or for a Review of the assessment of the dispute has been finalised.
YOU MUST LODGE A SEPARATE APPLICATION FORM FOR EACH DISPUTE (E.G. PERMANENT IMPAIRMENT OR TREATMENT) YOU WISH TO HAVE RE-ASSESSED.
In accordance with clause 14.12 of the Medical Assessment Guidelines:
The further assessment will involve consideration of all aspects of the assessment afresh, and may include:
14.12.1 assessment of all the injuries assessed by the original Assessor in any previous assessment of this dispute;
and
14.12.2 any additional injuries listed on the application for further assessment and any reply.
Instructions on completing the application form:
1.  The applicant must complete the application form and send it to:
a.  the respondent, together with a single sided copy of all material in support of the application that has not previously been supplied to the respondent; and
b.  MAS, with a total of two single sided copies of the application and all material in support of the application. Claimants without legal representation only need to lodge one single sided copy of the application form and the supporting documents at MAS.
2.  All documents attached to this application must be listed at question 9 of this form. You must clearly number the first page of each document at the top right hand corner in accordance with that list.
3.  In accordance with clause 12.10 of the Medical Assessment Guidelines:
No additional documents or information sought to be added to the list of documents to be referred to the
Assessor may be lodged by either party after the lodgement of their application or their reply, except:
12.10.1 by consent of the other party;
12.10.2 in response to a specific request or direction from the Proper Officer, an Assessor or an officer of
MAS, in circumstances where the Proper Officer is satisfied that any such document would be of
assistance to the conduct of the assessment; or
12.20.3 if the Proper Officer is satisfied that exceptional circumstances exist;
and any such documents must have been provided to the other party.
4. You should clearly mark the box that applies with a cross, e.g.
NOTE: A separate application is required for each motor accident claim for which assessment is sought. MAS may send material relating to any other dispute assessed by MAS for this claimant to the Assessor to assist the Assessor in assessing this dispute.
Where to send the application
Hand/Postal:
The Registrar, Medical Assessment Service
Motor Accidents Assessment Service
Motor Accidents Authority of NSW
Level 19, 1 Oxford St,
DARLINGHURST NSW 2010 / Document Exchange:
The Registrar, Medical Assessment Service
Motor Accidents Assessment Service
Motor Accidents Authority of NSW
DX 10 SYDNEY
1/11 / For assistance call the Claims Advisory Service on 1300 656 919 or visit www.maa.nsw.gov.au / 10/2008
INTERPRETER ASSISTANCE
If you need an interpreter service to help you read this form, contact:
Associated Translators & Linguists Pty Ltd
Level 5, 72 Pitt Street, Sydney, NSW 2000
P: 02 9231 3288 F: 02 9221 4763 www.atl.com.au
Office hours: 8.00 am to 5.30 pm (this interpreter service is provided free of charge to claimants).
If you need an interpreter to help you read this form, the declaration below must be completed by the interpreter and the claimant.
Interpreter Declaration
1.  We declare that the Claim Form has been read to the undersigned injured person by the undersigned interpreter.
2.  We understand that the Motor Accidents Authority of New South Wales and Associated Translators & Linguists Pty Limited bear no responsibility for any loss whatsoever arising from the interpreting service provided.
3.  We acknowledge that the interpreting service provided by Associated Translators & Linguists Pty Limited was limited to reading the claim form.
4.  This declaration has been read to the claimant by the undersigned interpreter.
Claimant’s name / ______
Claimant’s signature
Interpreter’s name / ______
Interpreter’s signature
Claimant’s address
Date
2/11 / For assistance call the Claims Advisory Service on 1300 656 919 or visit www.maa.nsw.gov.au / 10/2008
1. APPLICATION
This application is made by: / Claimant Claimant’s Legal Representative
Insurer Insurer’s Legal Representative
2. DETAILS ABOUT THE ACCIDENT
Date of Accident
Location of Accident
If you are the Claimant
Date completed Claim Form sent to the Insurer
If you are the Insurer
Date completed Claim Form received by the Insurer
3. CLAIMANT INFORMATION
(Details of the person who made this claim)
Title / Mr Ms Miss Mrs Dr Other
Surname/family name
Given name
Date of birth
Gender of Claimant / Male Female
Claimant Contact Details
Street Address
Suburb / State / Postcode
Country (if outside Australia)
Postal (If different to street address)
Suburb / State / Postcode
Country (if outside Australia)
Home Phone / Work Phone
Mobile Number / Fax Number
Does the Claimant prefer to communicate via email / Yes No (If Yes, all correspondence from MAAS will be by email)
Email
3/11 / For assistance call the Claims Advisory Service on 1300 656 919 or visit www.maa.nsw.gov.au / 10/2008
Contact Authority (Claimant to complete)
The Claimant hereby gives permission for MAAS and the Claims Advisory Service to contact the below named person who has been designated as an authorised contact person for this matter to discuss my claim if necessary.
Authorised Contact Name
Authorised Contact Number
Relationship to Claimant
(For example family, friend, lawyer)
Claimant Personal Information
Interpreter Required / No Yes / Language
Disabled Access Required / Visual Disability / Hearing Disability
Disability Details
Claimant Unavailable Dates
Claimant’s Legal Representative Details
Does this Claimant have a Legal Representative? / Yes No
(If yes, provide details below)
Firm
Postal Address or DX Address
(NSW DX only)
Suburb / State / Postcode
Claimant’s Legal Representative Name
Reference
Business Phone / Fax Number
Does the Legal Representative prefer to communicate via email? / Yes No (If Yes, all correspondence from MAAS will be by email)
Email
4/11 / For assistance call the Claims Advisory Service on 1300 656 919 or visit www.maa.nsw.gov.au / 10/2008
4. INSURER INFORMATION
Including NSW CTP Insurers, Interstate Insurers, the Nominal Defendant, other Corporations or Individuals against whom a claim is made.
(Select only one)
Is the person/entity against whom the claim is made a NSW CTP Insurer? / Yes No
Is the person/entity against whom the claim is made a non-NSW CTP Insurer? / Yes No
Is the person/entity against whom the claim is made a Corporation or an Individual? / Yes No
Details of CTP Insurer (or non-NSW CTP insurer)
Name of Insurer
Insurer Claim Number
Postal Address or DX Address
(NSW DX only)
Suburb / State / Postcode
Is the Insurer acting for the Nominal Defendant? / No Yes
Details of Claims Officer
Title / Mr Ms Miss Mrs Dr Other
Claims Officer Name
Business Phone / Fax Number
Does the Claims Officer prefer to communicate via email? / Yes No (If Yes, all correspondence from MAAS will be by email)
Email
Insurer’s Legal Representative Details
Does this Insurer have a Legal Representative? / Yes No
(If yes, provide details below)
Insurer’s Legal Representative Contact Details
Firm
Postal Address or DX Address
(NSW DX only)
Suburb / State / Postcode
Insurer’s Legal Representative Name
Reference
Business Phone / Fax Number
Does the Insurer’s Legal Representative prefer to communicate via email? / Yes No (If Yes, all correspondence from MAAS will be by email)
Email
5/11 / For assistance call the Claims Advisory Service on 1300 656 919 or visit www.maa.nsw.gov.au / 10/2008
Details of Corporation/Individual
(Complete this section if the claim is not made against a CTP Insurer. For example, a transport company, warehouse or employer.)
Name
Postal Address or DX Address
(NSW DX only)
Suburb / State / Postcode
Country (if outside Australia)
Business Phone / Fax Number
Does the Corporation/Individual prefer to communicate via email? / Yes No (If Yes, all correspondence from MAAS will be by email)
Email
Corporation/Individual’s Legal Representative Details
Does this Corporation/Individual have a Legal Representative? / Yes No
(If yes, provide details below)
Corporation/Individual’s Legal Representative Contact Details
Firm
Postal Address or DX Address
(NSW DX only)
Suburb / State / Postcode
Corporation/Individual’s Legal Representative Name
Reference
Business Phone / Fax Number
Does the Corporation/Individual’s Legal Representative prefer to communicate via email? / Yes No (If Yes, all correspondence from MAAS will be by email)
Email
6/11 / For assistance call the Claims Advisory Service on 1300 656 919 or visit www.maa.nsw.gov.au / 10/2008
5. DISPUTE INFORMATION
Grounds for further assessment
This application will be dismissed if:
·  you do not satisfy all four pre-requisites below;
·  you have not explained how the information provided could materially change the outcome of the previous assessment; and
·  you do not provide evidence in support of the application.
Further assessment pre-requisites
Has the dispute previously been assessed by a MAS Assessor? / Yes No
Have all certificates pertaining to that dispute been issued (including combined certificates and Review Panel certificates)? / Yes No
Has the time period for lodging applications for either a correction of an obvious error or Review, arising from the original assessment of that dispute, expired? / Yes No
Have all applications for correction of an obvious error or for a Review of the assessment of the dispute been completed? / Yes No N/A
NOTE: If you marked ‘No’ to any of the above questions your application will be rejected.
What is the reason for further assessment?
There has been deterioration of the injury or injuries sustained in the motor vehicle accident and this deterioration is capable, if the matter was to proceed to further assessment, of altering the outcome of the dispute from that certified in the previous assessment.
MAS Matter number/s of previous application:
There is additional relevant information about the injury or injuries sustained in the motor vehicle accident and this additional information is capable, if the matter was to proceed to further assessment, of altering the outcome of the dispute from that certified in the previous assessment.
MAS Matter number/s of previous application:
6. DETAILS ABOUT THE TREATMENT DISPUTE
You must give detailed reasons as to how any deterioration of the injury or additional relevant information about the injury is capable, if the matter was to proceed to further assessment, of altering the outcome of the dispute from that certified in the previous assessment.
(You MUST refer to particular sections or paragraphs of the documents you are providing in support)
Detailed reasons:
7/11 / For assistance call the Claims Advisory Service on 1300 656 919 or visit www.maa.nsw.gov.au / 10/2008
DISPUTE INFORMATION
7. DISPUTE ABOUT PAST TREATMENT
Do you have more than one dispute?
Yes / You must complete a separate Question 7 for each additional PAST treatment dispute.
If you have more than one PAST treatment dispute, copy this page and complete a separate question 7 for each additional PAST treatment dispute
No
Type of Treatment in dispute
e.g.’ physiotherapy’, ‘surgery’ or ‘medication’. / List all Details for this dispute
For treatment types e.g. ‘attendant care services’, ‘dental treatment’, ‘domestic assistance’, ‘gratuitous care, ‘herbal remedies’, ‘home modifications’, ‘medication-over the counter’, ‘medication-prescription’, radiological scans’, surgery-L5/S1 fusion’, or ‘other’. / Are supporting documents attached? / Supporting document numbers as per list of documents attached at question 9
Yes
No
Which injury was this treatment for?
e.g. ‘back’ or ‘care needs arising from all injuries’.
Who provided this treatment?
e.g. ‘Oxford St Physiotherapy’.
What period of treatment has the insurer refused to pay for?
e.g. ‘from 11/01/2005 to 01/03/2005’. / From / To
Number of session(s) in dispute for each period?
e.g. ‘two sessions per week’ or ‘6 hours per day’.
What is the date of the referral/recommendation for the treatment in dispute? / Date
When was the insurer requested to approve this treatment? / Date
Has the insurer responded to the request within 20 working days?
If you have not contacted the insurer, you should do so immediately. / Yes
No
If this application is lodged because the insurer has not responded, MAS will assess both whether the treatment is causally related and if reasonable and necessary.
What is the date of the letter from the insurer denying payment for the treatment in dispute or denying liability for the claim? / Date / N/A, (if you answered no to the previous question)
What reason has the insurer given for not paying for the treatment? / Not related to injuries caused by the accident
Not reasonable and necessary
8/11 / For assistance call the Claims Advisory Service on 1300 656 919 or visit www.maa.nsw.gov.au / 10/2008
DISPUTE INFORMATION
8. DISPUTE ABOUT PROPOSED FUTURE TREATMENT
Do you have more than one dispute?
Yes / You must complete a separate Question 8 for each additional PROPOSED FUTURE treatment dispute.
If you have more than one PROPOSED FUTURE treatment dispute, copy this page and complete a separate question 8 for each additional PROPOSED FUTURE treatment dispute.
No
Type of Treatment in dispute
e.g.’ physiotherapy’, ‘surgery’ or ‘medication’. / List all Details for this dispute
For treatment types e.g. ‘attendant care services’, ‘dental treatment’, ‘domestic assistance’, ‘gratuitous care, ‘herbal remedies’, ‘home modifications’, ‘medication-over the counter’, ‘medication-prescription’, radiological scans’, surgery-L5/S1 fusion’, or ‘other’. / Are supporting documents attached? / Supporting document numbers as per list of documents attached at question 9